Acute coronary syndrome (main): Difference between revisions
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*Type 3 - Cardiac Death Due to Myocardial Infarction | *Type 3 - Cardiac Death Due to Myocardial Infarction | ||
**suffer cardiac death with symptoms suggestive of myocardial ischaemia without elevated biomarkers | **suffer cardiac death with symptoms suggestive of myocardial ischaemia without elevated biomarkers | ||
*Type 4 -Myocardial Infarction Associated With Revascularization Procedure | *Type 4 - Myocardial Infarction Associated With Revascularization Procedure | ||
**4a: Related to PCI | **4a: Related to PCI | ||
**4b: Related to Stent Thrombosis | **4b: Related to Stent Thrombosis |
Revision as of 03:51, 13 November 2015
For risk stratification see ACS - Risk Stratification
Background
ACS is three diseases involving the coronary arteries:
- ST-Elevation Myocardial Infarction (STEMI) (30%)
- Non ST-Elevation Myocardial Infarction (NSTEMI) (25%)
- Unstable Angina (38%)
MI Types by Causation[1]
- Type 1 - Spontaneous Myocardial Infarction
- atherosclerotic plaque rupture or intraluminal thrombus in one or more of the coronary arteries
- Type 2 - Myocardial Infarction Secondary to an Ischaemic Imbalance
- condition other than CAD contributes to an imbalance between myocardial oxygen supply and/or demand
- Type 3 - Cardiac Death Due to Myocardial Infarction
- suffer cardiac death with symptoms suggestive of myocardial ischaemia without elevated biomarkers
- Type 4 - Myocardial Infarction Associated With Revascularization Procedure
- 4a: Related to PCI
- 4b: Related to Stent Thrombosis
- Type 5 - Myocardial Infarction Related to CABG Procedure
Clinical Features
Risk of ACS
Clinical factors that increase likelihood of ACS/AMI:[2][3]
- Chest pain radiating to both arms > R arm > L arm
- Chest pain associated with diaphoresis
- Chest pain associated with nausea/vomiting
- Chest pain with exertion
Clinical factors that decrease likelihood of ACS/AMI:[4]
- Pleuritic chest pain
- Positional chest pain
- Sharp, stabbing chest pain
- Chest pain reproducible with palpation
Gender differences in ACS
- Women with ACS:
- Less likely to be treated with guideline-directed medical therapies[5]
- Less likely to undergo cardiac catheterization[5]
- Less likely to receive timely reperfusion therapy[5]
- More likely to report fatigue, dyspnea, indigestion, nausea or vomiting, palpitations, or weakness,[5] although some studies have found fewer differences in presentation[6]
- More likely to delay presentation[5]
- Men with ACS:
- More likely to report central chest pain
Factors associated with delayed presentation[5]
- Female sex
- Older age
- Black or Hispanic race
- Low educational achievement
- Low socioeconomic status
Differential Diagnosis
Chest pain
Critical
- Acute coronary syndromes (ACS)
- Aortic dissection
- Cardiac tamponade
- Coronary artery dissection
- Esophageal perforation (Boerhhaave's syndrome)
- Pulmonary embolism
- Tension pneumothorax
Emergent
- Cholecystitis
- Cocaine-associated chest pain
- Mediastinitis
- Myocardial rupture
- Myocarditis
- Pancreatitis
- Pericarditis
- Pneumothorax
Nonemergent
- Aortic stenosis
- Arthritis
- Asthma exacerbation
- Biliary colic
- Costochondritis
- Esophageal spasm
- Gastroesophageal reflux disease
- Herpes zoster / Postherpetic Neuralgia
- Hypertrophic cardiomyopathy
- Hyperventilation
- Mitral valve prolapse
- Panic attack
- Peptic ulcer disease
- Pleuritis
- Pneumomediastinum
- Pneumonia
- Rib fracture
- Stable angina
- Thoracic outlet syndrome
- Valvular heart disease
- Muscle sprain
- Psychologic / Somatic Chest Pain
- Spinal Root Compression
- Tumor
Elevated Troponin
True Positive
False (Non-CAD) Positives
- Pericarditis
- Myocarditis
- PE
- CHF
- Sepsis
- Dissection
- Arrhythmias
- CVA
- SAH
- Burns
- Renal failure
- Assume true positive until proven otherwise
- ESRD
- 86% elevated predialysis in troponin-T
- 6% elevated predialysis in troponin-I
- no difference in post-MI troponin-I clearance rate in ESRD vs. normal GFR
- Cardioversion
- Cardiotoxic medications
- Amyloidosis
- Rheumatoid Factor
- Heterophilic antibodies
- Apical ballooning syndrome
- Cardiac procedures (surgery, ablation, pacing, stenting)
- Extreme exertion
Diagnosis
Workup
- ECG (Diagnosis)
- ECG is normal in 8% of all confirmed MI's
- In LBBB see Sgarbossa's Criteria
- Cardiac Enzymes
Evaluation
ACS Anatomical Correlation Chart
Ischemic Changes | Location | Coronary Artery |
STE V1-V3, TWI Q waves in V1-V3 over time |
Septal | Septal branch |
STE V2-V4 | Anterior | LAD |
STE I, aVL, V5, V6 STD inf leads |
Lateral | Circumflex |
STE I, aVL, V2-6 | Anterolateral | LAD + circumflex = Left main or 2 critical lesions |
STE II, III, aVF STD in aVL (most common lead to see reciprocal change) |
Inferior | RCA |
STE V1 (only lead looking at RV)
|
Right ventricle | RCA |
STD in V1, V2, V3; |
Posterior aka Inferolateral | RCA (90%), LCA (10%) |
STE avR>V1 Doesn't apply in SVT |
Anterolateral | Left Main |
Treatment
Intensity of treatment should be based on ACS likelihood
- ST-Elevation Myocardial Infarction (STEMI)
- Non ST-Elevation Myocardial Infarction (NSTEMI)
- Unstable Angina
Disposition
- Admit all ACS pts
Prognosis
External Links
- MDCalc - Framingham Coronary Heart Disease Risk Score
- MDCalc - Sgarbossa’s Criteria for MI in Left Bundle Branch Block
- MDCalc - TIMI Risk Score for UA/NSTEMI
See Also
- ACS - Risk Stratification
- ST-Elevation Myocardial Infarction (STEMI)
- ACS - Stress Testing
- NSTEMI
- Unstable Angina
- Unstable Angina - NSTEMI Guidelines
- Cocaine Chest Pain
- STEMI equivalents
References
- ↑ Third Universal Definition of Myocardial Infarction http://circ.ahajournals.org/content/126/16/2020.full.pdf
- ↑ Body R, Carley S, Wibberley C, et al. The value of symptoms and signs in the emergent diagnosis of acute coronary syndromes. Resuscitation. 2010;81(3):281–286. PMID: 20036454
- ↑ Panju AA, Hemmelgarn BR, Guyatt GH, et al. The rational clinical examination. Is this patient having a myocardial infarction? JAMA. 1998;280(14):1256–1263. PMID: 9786377
- ↑ Swap CJ, Nagurney JT. Value and limitations of chest pain history in the evaluation of patients with suspected acute coronary syndromes. JAMA. 2005;294(20):2623–2629. PMID: 16304077
- ↑ 5.0 5.1 5.2 5.3 5.4 5.5 Mehta LS, et al. Acute myocardial infarction in women: A scientific statement from the American Heart Association. Circulation. 2016; 133:916-947.
- ↑ Gimenez MR, et al. Sex-specific chest pain characteristics in the early diagnosis of acute myocardial infarction. JAMA Intern Med. 2014; 174(2):241-249.